Case 1: 40-Year-Old Patient With Acute Pain

Benjamin W. Friedman, MD, MS: I’d like to move the discussion toward specific cases and see if we can focus on specific management strategies for different types of patients. Let me present this first case to you. This is a 40-year-old man who presented to his primary care doctor because of severe pain in his big toe. Five days earlier, he presented to the emergency department and was diagnosed with gout. He was given naproxen 500 mg twice daily, colchicine 0.6 mg daily, and allopurinol. Aside from gout, his past medical history is remarkable for diabetes and obesity. He doesn’t report any allergies to medication. Professionally, he’s a truck driver. He smokes about a pack of cigarettes a day. He recently divorced. He reports that he was a recreational drug user in high school: marijuana. He has no local family besides his ex-wife.

He reports the following pain scores: On day 1, the day after leaving the emergency department, his pain is about a 6. On day 2, after a bit of activity, it moves up to a 7. On day 3, it remains about a 7 and is beginning to get worse when he comes in to see you. On physical examination, the first MTP [metatarsophalangeal joint] is swollen and red. It feels a bit warm. It’s quite consistent with a diagnosis of gout.

Transcript Edited for Clarity